Benefit of primary and secondary prophylactic implantable cardioverter defibrillator in elderly patients

$\bf Background$ The benefit of implantable cardioverter-defibrillator (ICD) in elderly patients has been questioned. In the present study, we aimed to analyse the outcome of patients of different age groups with ICD implantation. $\bf Methods$ We included all patients who received an ICD in our hospital from 2011 to 2020. Primary endpoints were (1) death from any cause and (2) appropriate ICD therapy (antitachycardia pacing/shock). A "benefit of ICD implantation" was defined as appropriate ICD therapy before death from any cause/or survival. "No benefit of ICD implantation" was defined as death from any cause without prior appropriate ICD therapy. $\bf Results$ A total of 422 patients received an ICD (primary prophylaxis $\it n$ = 323, secondary prophylaxis $\it n$ = 99). At the time of implantation, 35 patients (8%) were >80 years and 106 patients were >75 years (25%). During the study period of 4.2 $\pm$ 3 years, benefit of ICD occurred in 89 patients (21%) and no benefit in 84 patients (20%). In primary prevention, the proportion of patients who had a benefit from ICD implantation decreased with increasing age, and there were no patients who benefited from ICD therapy in the group of patients >80 years. In secondary prophylaxis, the proportion of patients with a benefit from ICD implantation ranged from 20% to 30% in all age groups. $\bf Conclusion$ Our study suggests that the indication of primary prophylactic ICD in elderly and very old patients should be critically assessed. On the other hand, no patient should be denied secondary prophylactic ICD implantation because of age

EKOSTMEKOS^{TM} in octogenarians

Background: Pulmonary embolism (PE) is a common cardiovascular disease. Elderly patients with acute PE have very high mortality rates. Data concerning the safety and effectiveness of ultrasound-accelerated thrombolysis (USAT) in this age group are lacking. Methods: Nineteen octogenarians with acute pulmonary embolism underwent USAT between August 2020 and February 2023 at two centres in Germany and were retrospectively analysed. The main efficacy measures were the right ventricle to left ventricle diameter (RV/LV) ratio, systolic right ventricle function, and invasive and echocardiographic measured systolic pulmonary artery pressure (sPAP). The main safety measures were in-hospital death and the bleeding rate according to the GUSTO bleeding score. Results: USAT was associated with an improved RV/LV ratio (0.36 $\pm$ 0.29, $\it p$ < 0.001), systolic right ventricle function (5.0 $\pm$ 3.8, $\it p$ < 0.001), and systolic pulmonary artery pressure (sPAP) at 24 h after therapy (24.2 $\pm$ 11.2 mmHg and 19 $\pm$ 13.4 mmHg, $\it p$ < 0.001). No in-hospital deaths or bleeding complications occurred. Conclusions: USAT with $EKOS^{TM}$ may be a safe and effective therapeutic option for octogenarians with acute pulmonary embolism

Urokinase versus alteplase in patients with intermediate-high-risk pulmonary embolism treated with ultrasound-accelerated endovascular thrombolysis

Background. Ultrasound-accelerated thrombolysis (USAT) is a safe and effective treatment for patients with intermediate–high-risk pulmonary embolism (PE). In all studies investigating USAT in the setting of PE, the recombinant tissue-plasminogen activator (rt-PA) alteplase or actilyse was used. Currently, there is a shortage of alteplase (Alteplase, Boehringer Ingelheim) in Europe. It is unknown whether the efficacy of urokinase (UK) is comparable with alteplase for USAT in patients with PE. Methods. Patients with intermediate–high-risk PE undergoing USAT with urokinase and alteplase were included in this study. One-to-one nearest neighbour matching was performed to account for baseline differences. We identified one patient treated with USAT and UK ($\it n$ = 9) for each patient treated with USAT and alteplase ($\it n$ = 9). Results. A total of 56 patients underwent USAT. The treatment was successful in all patients. The propensity score matched the identified nine pairs of patients. There were no statistically significant differences in the change in right ventricle-to-left ventricle (RV/LV) ratio (0.4 $\pm$ 0.3 versus 0.5 $\pm$ 0.4, $\it p$ = 0.54), systolic pulmonary artery pressure (17.3 $\pm$ 8.0 versus 18.1 $\pm$ 8.1, $\it p$ = 0.17), or improvement of RV function (5.8 $\pm$ 3.8 versus 5.1 $\pm$ 2.6, $\it p$ = 1.0). The complication rates were comparable (11% in both groups, $\it p$ = 0.55). There were no deaths in hospital or during 90 days in either group. Conclusions. In this case-matched comparison, the short-term clinical and echocardiographic outcomes showed comparable results between USAT–UK and USAT–rt-PA

Short- and long-term outcome of patients with spontaneous echo contrast or thrombus in the left atrial appendage in the era of the direct acting anticoagulants

$\bf Background$ Thrombi and spontaneous echo contrast (SEC) in the left atrial appendage (LAA) are associated with thromboembolic events and poor prognosis. There are very few data on long-term outcome, especially with the use of direct acting anticoagulants (DOAC). $\bf Methods$ In this retrospective study, all transoesophageal echocardiographies performed at a tertiary care university hospital from 2015 to 2020 were analyzed. All patients with thrombus or SEC in the LAA were included. Medical history, laboratory, echocardiographic parameters and medication at discharge were documented. The primary endpoint of the study was a composite endpoint (all-cause mortality, non-fatal stroke or transient ischaemic attack [TIA], non-fatal systemic embolization, non-fatal major bleeding and non-fatal myocardial infarction). $\bf Results$ Of a total of 4062 transoesophageal echocardiographies, thrombi were detected in 51 patients (1.2%) and SEC in 251 patients (6.2%). These patients formed the final study cohort ($\it n$ = 302). During a mean follow-up period of 956 $\pm$ 663 days, 87 patients (29%) suffered the primary point. The following baseline characteristics predicted the primary endpoint: age, haemoglobin, a previous coronary artery bypass grafting, dialysis and choice of anticoagulation. Prescription of apixaban at discharge was associated with lower rate of adverse events (hazard ratio 0.564, confidence interval 0.331–0.960; $\it p$ = 0.035) while prescription of dabigatran was associated with higher rate of adverse events (hazard ratio 3.091, confidence interval 1.506–6.347; $\it p$ = 0.002). $\bf Conclusion$ Even in the DOAC era, the occurrence of thrombus or SEC in the LAA is associated with a high rate of MACCE. Our study suggests that the choice of DOAC therapy may have an impact on long-term survival

P-wave parameters and their association with thrombi and spontaneous echo contrast in the left atrial appendage

$\bf Background:$ The aim of this study was to examine the prevalence of abnormal P-wave parameters in patients with thrombus and/or spontaneous echo contrast (SEC) in the left atrial appendage (LAA), and to identify P-wave parameters particularly associated with thrombus and SEC formation. $\bf Hypothesis:$ We presume a significant relationship of P-wave parameters with thrombi and SEC. $\bf Methods:$ All patients in whom a thrombus or SEC was detected in the LAA on transoesophageal echocardiography were included in this study. Patients at risk (CHA2DS2-VASc Score $\geq$3) and routine transoesophageal echocardiography to exclude thrombi served as the control group. A detailed ECG analysis was performed. $\bf Results:$ Of a total of 4062 transoesophageal echocardiographies, thrombi and SEC were detected in 302 patients (7.4%). Of these patients, 27 (8.9%) presented with sinus rhythm. The control group included 79 patients. There was no difference in mean CHA2DS2-VASc score in the two groups ($\it p$ = .182). A high prevalence of abnormal P-wave parameters was detected in patients with thrombus/SEC. Indicators for the presence of thrombi or SEC in the LAA were P-wave duration >118 ms (Odds ratio (OR) 3.418, Confidence interval (CI) 1.522–7.674, $\it p$ 40 ms (OR 2.521, CI 1.390–4.571, $\it p$ < .001) and advanced interatrial block (OR 1.431, CI 1.033–1.984, $\it p$ = .005). $\bf Conclusion:$ Our study revealed that several P-wave parameters are associated with thrombi and SEC in the LAA. The results may help identify patients who are at particularly high risk for thromboembolic events (e.g., in patients with embolic stroke of undetermined source)

Rate of atrial fibrillation and flutter induced tachycardiomyopathy in a cohort of hospitalized patients with heart failure and detection of indicators for improved diagnosis

$\bf Background:$ Atrial fibrillation (AF) and atrial flutter (AFL) induced tachycardiomyopathy (TCM) has been known to cause reversible heart failure (HF) for many years. However, the prevalence of the disease is unknown, and diagnosis is challenging. Therefore, the aim of the present study was (1) to assess the rate of AF/AFL induced TCM and (2) to identify indicators for diagnosis. $\bf Methods:$ Consecutively, all patients with a diagnosis of HF who were hospitalized in our department within 12 months were reviewed. For the main analysis, all patients with HF with reduced ejection fraction (HFrEF) and AF or AFL were included. AF/AFL induced TCM was diagnosed when there was at least a 10% improvement in left ventricular ejection fraction under rhythm or rate control within 3 months. Patients with HFrEF with AF/AFL but without TCM served as control group. $\bf Results:$ A total of 480 patients were included. AF/AFL induced TCM occurred in 26 patients (5.4%) and HFrEF with AF/AFL in 53 patients (11%). Independent indicators of AF/AFL induced TCM were age112 bpm (Odds ratio 2.503, CI 1.288–4.864, $\it p$ = 0.001). $\bf Conclusion:$ Approximately 5% of all patients hospitalized for HF suffer from AF/AFL induced TCM. Improved discrimination of AF/AFL induced TCM to HFrEF with AF/AFL is possible considering age, NT-pro-BNP level, and resting heart rate >112 beats/minute. Based on these parameters, an earlier diagnosis and improved therapy might be possible

Endocarditis following ocrelizumab in relapsing-remitting MS

Ocrelizumab is a monoclonal anti-CD20 antibody targeting B cells, which is authorized for relapsing-remitting MS (RRMS) and active primary progressive MS. Here, we report, to the best of our knowledge, the first case of infective endocarditis in a patient treated with ocrelizumab

In-hospital triggers of takotsubo syndrome

$\bf Background$ Takotsubo syndrome (TTS) is characterized by acute left ventricular dysfunction, mimicking an acute myocardial infarction, in the absence of obstructed coronary arteries. It is often triggered by physical or emotional stress, with catecholamines playing a central role in its pathophysiology. Recent advances have been made in categorizing TTS patients based on trigger events and comorbidities, as well as proposed classifications differentiating primary and secondary TTS. In-hospital triggers for (secondary) TTS appear to be quite common, and our aim is to bring attention of this prevalent phenomenon. $\textbf {Case summary}$ We present the clinical course of an 80-year-old man who developed TTS after witnessing the sudden death of his roommate during his hospital stay. Initially hospitalized for bradycardia and complete atrioventricular block, the patient was discharged after a pacemaker implantation. However, he returned to the hospital 3 days later with chest pain and other symptoms indicative of TTS. Diagnostic tests confirmed apical ballooning consistent with TTS, and subsequent echocardiograms showed a substantial improvement in left ventricular function. $\bf Discussion$ The case is classified as in-hospital TTS, occurring unexpectedly during medical care, and suggests that secondary TTS could represent a certain ‘basic risk’ for hospitalized patients. We want to emphasize the importance of reducing pain and fear in the hospital setting and encourage further research to understand the association between TTS and medical procedures and therapies. Overall, this case underscores the need for strategies to reduce the frequency of TTS in hospitalized patients

The molecular mechanisms associated with the physiological responses to inflammation and oxidative stress in cardiovascular diseases

The complex physiological signal transduction networks that respond to the dual challenges of inflammatory and oxidative stress are major factors that promote the development of cardiovascular pathologies. These signaling networks contribute to the development of age-related diseases, suggesting crosstalk between the development of aging and cardiovascular disease. Inhibition and/or attenuation of these signaling networks also delays the onset of disease. Therefore, a concept of targeting the signaling networks that are involved in inflammation and oxidative stress may represent a novel treatment paradigm for many types of heart disease. In this review, we discuss the molecular mechanisms associated with the physiological responses to inflammation and oxidative stress especially in heart failure with preserved ejection fraction and emphasize the nature of the crosstalk of these signaling processes as well as possible therapeutic implications for cardiovascular medicine

The safety and efficacy of ultrasound-accelerated catheter-directed thrombolysis in patients with intermediate–high-risk pulmonary embolism

Ultrasound-accelerated thrombolysis (USAT) is an advanced interventional therapy for patients with intermediate–high-risk pulmonary embolism (PE) who deteriorated on anticoagulation or for high-risk patients for whom systemic thrombolysis is contraindicated. The aim of this study is to investigate the safety and efficacy of this therapy with a focus on the improvement of vital signs and laboratory parameters. Seventy-nine patients with intermediate–high-risk PE were treated with USAT from August 2020 to November 2022. The therapy significantly decreased the mean RV/LV ratio from 1.2 $\pm$ 0.22 to 0.9 $\pm$ 0.2 ($\it p$ < 0.001) as well as the mean PAPs from 48.6 $\pm$ 11 to 30.1 $\pm$ 9.0 mmHg ($\it p$ < 0.001). The respiratory and heart rate decreased significantly ($\it p$ < 0.001). Serum creatinine decreased significantly from 1.0 $\pm$ 0.35 to 0.9 $\pm$ 0.3 ($\it p$ < 0.001). There were 12 access-associated complications, which could be treated conservatively. One patient had haemothorax after the therapy and had to be operated on. USAT is an effective therapy for patients with intermediate–high-risk PE, with favourable hemodynamic, clinical, and laboratory outcomes